Long-term quality of life after swallowing and salivary-sparing chemo-intensity modulated radiation therapy in survivors of human papillomavirus-related oropharyngeal cancer

Self-management intervention improves patient adherence to swallowing exercises during radiation for head and neck cancer

BACKGROUND

While preventive swallowing exercises reduce the risk of radiation-associated dysphagia in patients with head and neck cancer, strategies are needed to improve patient adherence.

METHODS

Before radiation, all participants were taught preventive swallowing exercises and randomized to either an adherence intervention or enhanced usual care. During radiation, all participants met twice with a speech pathologist for swallowing assessment and reinforcement of exercises. Intervention participants met weekly with a counselor in-person or by phone. At 6-week post-radiation follow-up, all participants completed a follow-up assessment of self-reported adherence, which was then corroborated with medical record documentation.

RESULTS

Newly diagnosed pharyngeal and laryngeal cancer patients without distant metastases were randomized (n = 265; 135 to intervention, and 130 to usual care). Intervention participants were more likely to adhere to exercises during radiation compared to the control group (p < 0.0001).

CONCLUSION

The weekly in-person adherence intervention program significantly increased patient's adherence to preventive swallowing exercises during radiation.

Iterative Patient Testing of a Stimuli-Responsive Swallowing Activity Sensor to Promote Extended User Engagement During the First Year After Radiation: Multiphase Remote and In-Person Observational Cohort Study

BACKGROUND

Frequent sensor-assisted monitoring of changes in swallowing function may help improve detection of radiation-associated dysphagia before it becomes permanent. While our group has prototyped an epidermal strain/surface electromyography sensor that can detect minute changes in swallowing muscle movement, it is unknown whether patients with head and neck cancer would be willing to wear such a device at home after radiation for several months.

OBJECTIVE

We iteratively assessed patients' design preferences and perceived barriers to long-term use of the prototype sensor.

METHODS

In study 1 (questionnaire only), survivors of pharyngeal cancer who were 3-5 years post treatment and part of a larger prospective study were asked their design preferences for a hypothetical throat sensor and rated their willingness to use the sensor at home during the first year after radiation. In studies 2 and 3 (iterative user testing), patients with and survivors of head and neck cancer attending visits at MD Anderson's Head and Neck Cancer Center were recruited for two rounds of on-throat testing with prototype sensors while completing a series of swallowing tasks. Afterward, participants were asked about their willingness to use the sensor during the first year post radiation. In study 2, patients also rated the sensor's ease of use and comfort, whereas in study 3, preferences were elicited regarding haptic feedback.

RESULTS

The majority of respondents in study 1 (116/138, 84%) were willing to wear the sensor 9 months after radiation, and participant willingness rates were similar in studies 2 (10/14, 71.4%) and 3 (12/14, 85.7%). The most prevalent reasons for participants' unwillingness to wear the sensor were 9 months being excessive, unwanted increase in responsibility, and feeling self-conscious. Across all three studies, the sensor's ability to detect developing dysphagia increased willingness the most compared to its appearance and ability to increase adherence to preventive speech pathology exercises. Direct haptic signaling was also rated highly, especially to indicate correct sensor placement and swallowing exercise performance.

CONCLUSIONS

Patients and survivors were receptive to the idea of wearing a personalized risk sensor for an extended period during the first year after radiation, although this may have been limited to well-educated non-Hispanic participants. A significant minority of patients expressed concern with various aspects of the sensor's burden and its appearance.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03010150; https://clinicaltrials.gov/study/NCT03010150.

Long-term outcomes of stimulated salivary flow and xerostomia after definitive intensity-modulated radiation therapy for patients with head and neck cancer†

This retrospective study aimed to evaluate the time to recovery from xerostomia and analyze its predictors, along with long-term outcomes of stimulated salivary flow after intensity-modulated radiation therapy (IMRT) for head and neck cancer (HNC). We evaluated patients with HNC who had received IMRT with curative intent between 2012 and 2018 at our institution. The salivary recovery ratio (SRR) was defined as '(the stimulated salivary flow)/(pre-treatment salivary flow)'. The cutoff value of SRR in salivary recovery was estimated via the relationship between SRR and xerostomia grades. The salivary recovery time was defined as the time for SRR to exceed cutoff values from the end of radiotherapy. Fifty-seven patients were analyzed, with a 48-month median follow-up period of stimulated salivary flow. The cutoff value for SRR was 44.8%, and patients with a higher grade of xerostomia had a lower SRR (P < 0.001). The median salivary recovery time was 12 months. The cumulative incidence rates of salivary recovery at two and four years were 84 (95% confidence interval [CI]: 53-79) and 92% (95% CI: 82-97), respectively, and these were significantly lower in patients with a higher mean parotid gland dose, mean oral cavity dose and stimulated salivary flow per parotid gland volume. Stimulated salivary flow and xerostomia recover over a long period after radiotherapy.

Quality of Life After Neoadjuvant Chemotherapy and Transoral Robotic Surgery for Oropharynx Cancer

Importance

Efforts are underway to deintensified treatment protocols for patients with human papillomavirus virus-associated oropharyngeal squamous cell carcinoma (HPV-OPSCC) to achieve similar excellent oncologic outcomes while reducing treatment-related adverse effects. Transoral robotic surgery (TORS) as primary treatment often requires adjuvant therapy due to the high incidence of nodal metastasis. Treatment with neoadjuvant chemotherapy followed by TORS and neck dissection (NECTORS), reserving radiation therapy for salvage, yields excellent oncologic outcomes.

Objective

To assess patient-reported quality of life (QOL) and functional outcomes among patients with HPV-OPSCC who undergo NECTORS.

Design, Settings, and Participants

This was a multicenter prospective cohort study of patients with HPV-OPSCC treated with the NECTORS protocol in 2017 to 2022. Consecutive patients with stage III or IVa HPV-OPSCC treated with NECTORS in 2017 to 2022 who had completed the primary QOL questionnaire at baseline and at least once during the 24-month follow-up period were included. Ninety-four patients were eligible, and 67 were included in the analyses.

Outcome Measures

QOL questionnaires at baseline, and at month 1, 3, 6, 12, 18, and 24 posttreatment. Global score on the 30-item European Organization for Research and Treatment of Cancer Core quality of life questionnaire (EORTC QLQ-C30) was the primary outcome; the head and neck extension module (EORTC QLQ-HN35); the MD Anderson Dysphagia Inventory for dysphagia-related QOL; and the Decision Regret Scale were also used. Paired t tests assessed change between the baseline and 12- or 24-month patient-reported outcomes.

Results

Among the study population of 67 patients (median [range] age, 63 [58-67] years; 54 [80.6%] male) with HPV-OPSCC, the most frequent cancer subsites were palatine tonsil (41 [61%]) and base of tongue (26 [39%]); none required adjuvant RT. Global QOL at 24 months improved compared with baseline (mean difference, 9.49; 95% CI, 2.45 to 16.53). All EORTC QLQ-C30 functional scores returned to baseline or improved within 3 to 6 months posttreatment and remained stable at 24 months. EORTC QLQ-HN35 symptom scale scores improved or were stable at 24 months. The MD Anderson Dysphagia Inventory scores demonstrated no significant difference between baseline and month 12 for global scores (mean difference, 6.15; 95% CI, -4.18 to 16.49) and composite scores (mean difference, 2.73; 95% CI, -1.62 to 7.09). Median (range) score on the Decision Regret Scale was 5 of 100 (0-30), representing mild overall regret.

Conclusion and Relevance

The findings of this multicenter cohort study indicate that use of the NECTORS protocol is associated with excellent QOL outcomes. QOL measures returned to baseline levels or were better than baseline, which represents positive outcomes for patients with HPV-OPSCC who undergo this treatment regimen.

A Descriptive Study of Quality of Life Following Neoadjuvant Chemotherapy and Transoral Robotic Surgery for Human Papillomavirus-Associated Oropharyngeal Squamous Cell Carcinoma

BACKGROUND

Patients with oropharyngeal squamous cell carcinoma (OPSCC) treated with radiation-based therapy suffer from short- and long-term toxicities that affect quality of life (QOL). Transoral robotic surgery (TORS) has an established role in the management of early OPSCC but adjuvant treatment is often indicated postoperatively due to the high incidence of nodal metastasis associated with advanced human papillomavirus (HPV)-related OPSCC. To overcome the need for adjuvant radiation therapy (RT), neoadjuvant chemotherapy followed by TORS and neck dissection (ND) is proposed. This study aimed to assess if QOL in HPV-associated OPSCC receiving neoadjuvant chemotherapy followed by TORS and ND returns to baseline within 12 months of completing treatment.

METHODS

A 12 month longitudinal study was carried out at McGill University Health Centre in Montreal, Canada, among a convenience sample of patients with American Joint Committee on Cancer Seventh Edition stage III and IVa HPV-related OPSCC who were treated with neoadjuvant chemotherapy followed by TORS and ND. QOL data were obtained pretreatment and at 1, 3, 6, and 12 months following treatment completion using the European Organisation for Research and Treatment of Cancer Core and Head and Neck extension modules. Paired t tests and mixed models for repeated measures analysis were used to assess changes in QOL from baseline to 12 months postoperatively and over time, respectively.

RESULTS

Nineteen of 23 patients (median age 58 years) who received the study treatment fulfilled the eligibility criteria. OPSCC subsites were palatine tonsil (n = 12) and base of tongue (n = 7). All 19 patients were treated per protocol and none required adjuvant RT as per pathology review and protocol requirements at a postoperative multidisciplinary team tumor board discussion. No significant differences were found when comparing 12 month QOL follow-up scores to pretreatment scores in measures that would likely be affected by RT [eg, swallowing (P = .7), social eating (P = .8), xerostomia (P = .9)].

CONCLUSION

In HPV-related OPSCC, neoadjuvant chemotherapy followed by TORS and ND as definitive treatment is associated with excellent QOL outcomes. Postoperative QOL scores returned to baseline by 3 months and were maintained for all measures, indicating a return to normal function.

Dysphagia-optimised intensity-modulated radiotherapy versus standard intensity-modulated radiotherapy in patients with head and neck cancer (DARS): a phase 3, multicentre, randomised, controlled trial

BACKGROUND

Most newly diagnosed oropharyngeal and hypopharyngeal cancers are treated with chemoradiotherapy with curative intent but at the consequence of adverse effects on quality of life. We aimed to investigate if dysphagia-optimised intensity-modulated radiotherapy (DO-IMRT) reduced radiation dose to the dysphagia and aspiration related structures and improved swallowing function compared with standard IMRT.

METHODS

DARS was a parallel-group, phase 3, multicentre, randomised, controlled trial done in 22 radiotherapy centres in Ireland and the UK. Participants were aged 18 years and older, had T1-4, N0-3, M0 oropharyngeal or hypopharyngeal cancer, a WHO performance status of 0 or 1, and no pre-existing swallowing dysfunction. Participants were centrally randomly assigned (1:1) using a minimisation algorithm (balancing factors: centre, chemotherapy use, tumour type, American Joint Committee on Cancer tumour stage) to receive DO-IMRT or standard IMRT. Participants and speech language therapists were masked to treatment allocation. Radiotherapy was given in 30 fractions over 6 weeks. Dose was 65 Gy to primary and nodal tumour and 54 Gy to remaining pharyngeal subsite and nodal areas at risk of microscopic disease. For DO-IMRT, the volume of the superior and middle pharyngeal constrictor muscle or inferior pharyngeal constrictor muscle lying outside the high-dose target volume had a mandatory 50 Gy mean dose constraint. The primary endpoint was MD Anderson Dysphagia Inventory (MDADI) composite score 12 months after radiotherapy, analysed in the modified intention-to-treat population that included only patients who completed a 12-month assessment; safety was assessed in all randomly assigned patients who received at least one fraction of radiotherapy. The study is registered with the ISRCTN registry, ISRCTN25458988, and is complete.

FINDINGS

From June 24, 2016, to April 27, 2018, 118 patients were registered, 112 of whom were randomly assigned (56 to each treatment group). 22 (20%) participants were female and 90 (80%) were male; median age was 57 years (IQR 52-62). Median follow-up was 39·5 months (IQR 37·8-50·0). Patients in the DO-IMRT group had significantly higher MDADI composite scores at 12 months than patients in the standard IMRT group (mean score 77·7 [SD 16·1] vs 70·6 [17·3]; mean difference 7·2 [95% CI 0·4-13·9]; p=0·037). 25 serious adverse events (16 serious adverse events assessed as unrelated to study treatment [nine in the DO-IMRT group and seven in the standard IMRT group] and nine serious adverse reactions [two vs seven]) were reported in 23 patients. The most common grade 3-4 late adverse events were hearing impairment (nine [16%] of 55 in the DO-IMRT group vs seven [13%] of 55 in the standard IMRT group), dry mouth (three [5%] vs eight [15%]), and dysphagia (three [5%] vs eight [15%]). There were no treatment-related deaths.

INTERPRETATION

Our findings suggest that DO-IMRT improves patient-reported swallowing function compared with standard IMRT. DO-IMRT should be considered a new standard of care for patients receiving radiotherapy for pharyngeal cancers.

FUNDING

Cancer Research UK.

Long-Term Update of NRG/RTOG 0522: A Randomized Phase 3 Trial of Concurrent Radiation and Cisplatin With or Without Cetuximab in Locoregionally Advanced Head and Neck Cancer

PURPOSE

The combination of cisplatin and radiation or cetuximab and radiation improves overall survival of patients with locoregionally advanced head and neck carcinoma. NRG Oncology conducted a phase 3 trial to test the hypothesis that adding cetuximab to radiation and cisplatin would improve progression-free survival (PFS).

METHODS AND MATERIALS

Eligible patients with American Joint Committee on Cancer sixth edition stage T2 N2a-3 M0 or T3-4 N0-3 M0 were accrued from November 2005 to March 2009 and randomized to receive radiation and cisplatin without (arm A) or with (arm B) cetuximab. Outcomes were correlated with patient and tumor features. Late reactions were scored using Common Terminology Criteria for Adverse Events (version 3).

RESULTS

Of 891 analyzed patients, 452 with a median follow-up of 10.1 years were alive at analysis. The addition of cetuximab did not improve PFS (hazard ratio [HR], 1.06; 95% confidence interval [CI], 0.89-1.26; P = .74), with 10-year estimates of 43.6% (95% CI, 38.8- 48.4) for arm A and 40.2% (95% CI, 35.4-45.0) for arm B. Cetuximab did not reduce locoregional failure (HR, 1.21; 95% CI, 0.95-1.53; P = .94) or distant metastasis (HR, 0.79; 95% CI, 0.54-1.14; P = .10) or improve overall survival (HR, 0.97; 95% CI, 0.80-1.16; P = .36). Cetuximab did not appear to improve PFS in either p16-positive oropharynx (HR, 1.30; 95% CI, 0.87-1.93) or p16-negative oropharynx or nonoropharyngeal primary (HR, 0.94; 95% CI, 0.73-1.21). Grade 3 to 4 late toxicity rates were 57.4% in arm A and 61.3% in arm B (P = .26).

CONCLUSIONS

With a median follow-up of more than 10 years, this updated report confirms the addition of cetuximab to radiation therapy and cisplatin did not improve any measured outcome in the entire cohort or when stratifying by p16 status.

World Workshop on Oral Medicine VIII: Development of a Core Outcome Set for Dry Mouth: A Systematic Review of Outcome Domains for Xerostomia

OBJECTIVE

The purpose of this study was to identify all outcome domains used in clinical studies of xerostomia, that is, subjective sensation of dry mouth. This study is part of the extended project "World Workshop on Oral Medicine Outcomes Initiative for the Direction of Research" to develop a core outcome set for dry mouth.

STUDY DESIGN

A systematic review was performed on MEDLINE, EMBASE, CINAHL, and Cochrane Central Register of Controlled Trials databases. All clinical and observational studies that assessed xerostomia in human participants from 2001 to 2021 were included. Information on outcome domains was extracted and mapped to the Core Outcome Measures in Effectiveness Trials taxonomy. Corresponding outcome measures were summarized.

RESULTS

From a total of 34,922 records retrieved, 688 articles involving 122,151 persons with xerostomia were included. There were 16 unique outcome domains and 166 outcome measures extracted. None of these domains or measures were consistently used across all the studies. The severity of xerostomia and physical functioning were the 2 most frequently assessed domains.

CONCLUSION

There is considerable heterogeneity in outcome domains and measures reported in clinical studies of xerostomia. This highlights the need for harmonization of dry mouth assessment to enhance comparability across studies and facilitate the synthesis of robust evidence for managing patients with xerostomia.

A two-step treatment planning strategy incorporating knowledge-based planning for head-and-neck radiotherapy

PURPOSE

There has been much research interest in automated head-and-neck (HN) planning with the goal of reducing planning time and inter-planner variability while improving plan quality. However, clinical uses are still limited and institution-dependent due to the plan complexity. This work aims to investigate whether the use of a novel semi-automated two-step optimization method (TSP) can improve the quality and efficiency of planning while providing a simple framework that other institutions can follow.

METHODS AND MATERIALS

Forty patients (two and three prescription isodose levels) were retrospectively studied. Plans were generated by TSP which incorporates a knowledge-based planning solution. Comparisons were performed for plan conformity and selected dose-volume indices between clinical plan (CP) and TSP. Blind reviews were carried out by 15 clinicians to determine preference between the CP and TSP, as well as clinical suitability.

RESULTS

For majority of patients studied, TSP had similar or slightly better conformity for the high-dose PTV, and better conformity for the low-dose PTV and 45 Gy isodose lines compared to CP. The only statistically significant difference observed for the serial organs was a reduction of the spinal cord maximum dose with TSP. Except for left parotid gland (D_mean and V₃₀ for both 2R× and 3R× groups) and oral cavity (D_mean for 3R× group), TSP had significant dose reductions for all parallel organs compared to CP. Blind reviewers either showed preference/no preference for 57.2%/21.7% (2R×) and 57.5%/27.8% (3R×) of TSP compared with CP. Excluding no preference votes, 60% of TSP were preferred. TSP was selected majority of the time when looking at the vote distribution for each patient individually.

CONCLUSION

Our TSP allows plans to be created within 90-min time frame while offering improvements in plan quality and less inter-planner variability as compared to traditional planning techniques.

A Prospective Study of Mucosal Sparing Radiation Therapy in Resected Oropharyngeal Cancer Patients

PURPOSE

Our objective was to report the prospective results of mucosal sparing radiation therapy in human papillomavirus-related oropharyngeal squamous cell carcinoma.

METHODS AND MATERIALS

From March 2016 through May 2019, patients were enrolled in this institutional review board-approved prospective cohort study at a multisite institution. Inclusion criteria included p16+ American Joint Committee on Cancer seventh edition pathologic T1 or T2, N1 to N3, and M0 oropharyngeal cancers. Proton therapy (PT) was delivered to at-risk nodal regions, excluding the primary mucosal site. Secondary to insurance denial for PT, intensity modulated radiation therapy (IMRT) was allowed. European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Head and Neck Module and Patient-Reported Outcomes Measurement Information System surveys (quality of life [QOL]) and modified barium swallowing impairment profiles (MBSImP) were obtained at baseline before radiation therapy, then 3 and 12 months after radiation therapy. Kaplan-Meier estimates were calculated for time-to-event clinical outcomes, and repeated measures mixed models were used to explore changes in QOL over time. A comparison of QOL and swallowing outcomes with standard-of-care treatment was analyzed.

RESULTS

There were 61 evaluable patients with a median follow-up of 38 months (range, 10-64); 44 (72%) were treated with PT and 17 (28%) were treated with IMRT. The 2-year local control, locoregional control, distant metastasis-free survival, and overall survival were 98%, 97%, 98%, and 100%, respectively. There were 6 grade ≥3 events related to treatment. Two IMRT patients required percutaneous endoscopic gastrostomy tube placement during treatment secondary to significant nausea due to dysgeusia. Patients noted significant QOL improvement over time in the pain, swallowing, speech, social eating, social contact, mouth opening, and use of pain medication domains (all P < .02). The MBSImP overall severity score as well as oral and pharyngeal impairment scores showed stability with no significant change over time. For the 44 patients treated with PT, the mean D95 to the primary target was 10.7 Gy (standard deviation = 12.5 Gy).

CONCLUSIONS

Mucosal sparing radiation is well tolerated in select resected human papillomavirus-related oropharyngeal squamous cell carcinoma with a low risk of recurrence at the mucosal primary site, a low rate of percutaneous endoscopic gastrostomy tube placement, and few radiation-related grade ≥3 adverse events.

Five-year survival outcomes in oropharyngeal squamous cell carcinoma following transoral laser microsurgery

Objective

To determine the 5-year survival outcomes of patients with oropharyngeal cancer treated with transoral laser microsurgery at our institution.

Methods

A prospective longitudinal cohort study of all cases of oropharyngeal squamous cell cancer or clinically unknown primaries diagnosed at our institution between September 1, 2014, to December 31, 2019, treated with primary transoral laser microsurgery were analyzed. Patients with a previous history of head and neck radiation were excluded from analysis. Kaplan-Meier survival curves were used to estimate 5-year overall survival, disease-specific survival, local control, and recurrence free survival rates in oropharyngeal squamous cell carcinoma.

Results

Of 142 patients identified, 135 met criteria and were included in the survival analysis. Five-year local control rates in p16 positive and negative disease were 99.2% and 100%, respectively, with one locoregional failure in the p16 positive cohort. Five-year overall survival, disease-specific survival, and recurrence free survival in p16 positive disease were 91%, 95.2%, and 87% respectively (n = 124). Five-year overall survival, disease-specific survival, and recurrence free survival in p16 negative disease were 39.8%, 58.3%, and 60%, respectively (n = 11). The permanent gastrostomy tube rate was 1.5% and zero patients received a tracheostomy at the time of surgery. One patient (0.74%) required a return to the OR for a post-operative pharyngeal bleed.

Conclusion

Transoral laser microsurgery is a safe primary treatment option for oropharyngeal squamous cell carcinoma with high 5-year survival outcomes, notably in p16 positive disease. More randomized trials are needed to compare survival outcomes and associated morbidity in transoral laser microsurgery compared to treatment with primary chemoradiation.

Level of Evidence

3.

Predicting radiotherapy-induced xerostomia in head and neck cancer patients using day-to-day kinetics of radiomics features

Background and purpose

The images acquired during radiotherapy for image-guidance purposes could be used to monitor patient-specific response to irradiation and improve treatment personalisation. We investigated whether the kinetics of radiomics features from daily mega-voltage CT image-guidance scans (MVCT) improve prediction of moderate-to-severe xerostomia compared to dose/volume parameters in radiotherapy of head-and-neck cancer (HNC).

Materials and Methods

All included HNC patients (N = 117) received 30 or more fractions of radiotherapy with daily MVCTs. Radiomics features were calculated on the contra-lateral parotid glands of daily MVCTs. Their variations over time after each complete week of treatment were used to predict moderate-to-severe xerostomia (CTCAEv4.03 grade ≥ 2) at 6, 12 and 24 months post-radiotherapy. After dimensionality reduction, backward/forward selection was used to generate combinations of predictors.Three types of logistic regression model were generated for each follow-up time: 1) a pre-treatment reference model using dose/volume parameters, 2) a combination of dose/volume and radiomics-based predictors, and 3) radiomics-based predictors. The models were internally validated by cross-validation and bootstrapping and their performance evaluated using Area Under the Curve (AUC) on separate training and testing sets.

Results

Moderate-to-severe xerostomia was reported by 46 %, 33 % and 26 % of the patients at 6, 12 and 24 months respectively. The selected models using radiomics-based features extracted at or before mid-treatment outperformed the dose-based models with an AUCtrain/AUCtest of 0.70/0.69, 0.76/0.74, 0.86/0.86 at 6, 12 and 24 months, respectively.

Conclusion

Our results suggest that radiomics features calculated on MVCTs from the first half of the radiotherapy course improve prediction of moderate-to-severe xerostomia in HNC patients compared to a dose-based pre-treatment model.

Long-term Toxicity, Swallow Function, and Quality of Life on MC1273, a Phase II Study of Dose De-escalation for Adjuvant Chemoradiation in HPV-Positive Oropharyngeal Cancer (HPV-OPC)

BACKGROUND

Patients with HPV-OPC are highly curable but risk significant long-term toxicity with standard therapy. This study investigated a de-escalation strategy of decreased adjuvant radiotherapy (RT) and chemotherapy after transoral robotic surgery, and reports on long-term functional and quality of life (QOL) outcomes.

METHODS

Eligible patients had a p16-positive OPC and ≤10 pack-year smoking history and underwent surgery followed by treatment with either 30 Gy delivered in 1.5-Gy fractions twice per day over 2 weeks with weekly docetaxel (15 mg/m²) if they had intermediate pathologic risk factors or 36 Gy in 1.8-Gy fractions twice per day over 2 weeks with the same chemotherapy if they had extranodal extension. Toxicity, swallow function, and QOL were measured longitudinally.

RESULTS

Seventy-nine patients (89.9% male) were treated and eligible for toxicity and functional evaluation. Dry mouth was the most common grade 1 toxicity at 1 year (55.6%), 2 years (53.3%) and 3 years (49.2%). The cumulative rates of grade 2 toxicities at 1, 2, and 3 years, were 1.4%, 6.7%, and 6.8%. There were only two grade 3 toxicities at ≥ 1 year, including a grade 3 fatigue at 2 ½ years, and a grade 3 superficial soft tissue fibrosis at 4 years. There were no grade 4-5 toxicities. No patients were PEG dependent. Swallow function improved by 12 months post-treatment. QOL improved over time by all measurement tools and most patients returned to baseline level of function and QOL.

CONCLUSION

De-escalated adjuvant therapy for select patients with HPV-OPC resulted in low rates of long-term toxicity, excellent swallow outcomes, and preservation of global and xerostomia-related QOL.

Tube feeding in head and neck cancer patients undergoing chemoradiotherapy: a systematic review

BACKGROUND

Head and neck cancer patients are frequently malnourished at the time of diagnosis and prior to the beginning of treatment. In addition, chemo-radiotherapy (CRT) causes or exacerbates symptoms, such as alteration or loss of taste, mucositis, xerostomia, fatigue, nausea, and vomiting, with consequent worsening of malnutrition. If obstructing cancer and/or mucositis interfere with swallowing, enteral nutrition should be delivered by a nasogastric tube (NGT) or percutaneous endoscopic gastrostomy (PEG).

AIM

To revise the studies comparing NGT and PEG in terms of nutritional outcomes, survival, hospitalizations, number of interruptions of radiotherapy, quality of life, swallowing function.

RESULTS

A total of 250 publications were identified via electronic databases. After screening the titles, abstracts and full texts, 26 manuscripts that met the inclusion criteria were included for analysis. We divided the analysis in two sections: 1) comparison of enteral nutrition through NGT or PEG and 2) comparison of reactive PEG (R-PEG) and prophylactic PEG (P-PEG).

RESULTS

Both PEG and NGT are an effective method of providing nutritional support during chemoradiotherapy for head and neck cancer. They are essentially comparable in terms of nutritional outcomes, number of radiotherapy interruptions, survival, and quality of life, whereas swallow function seems better with NGT. PEG may be associated with major complications such as exit site infection, malfunction, leakage, pain, and pulmonary infection and higher costs. Nevertheless, NGT dislodged more often, patients find it more inconvenient, may cause aspiration pneumonia and PEG has advantages over NGT of enhanced mobility and improved cosmesis. P-PEG and R-PEG are essentially similar in terms of nutritional outcomes, number of interruptions of radiotherapy, and survival. Conflicting results have been reported about quality of life.

CONCLUSION

PEG is not better than NGT in terms of nutritional, oncologic, and quality of life outcomes. Prophylactic feeding through NGT or PEG, compared to reactive feeding, does not offer significant advantages in terms of nutritional outcomes, interruptions of radiotherapy and survival. However, the number of prospective randomized studies on this topic is much limited and consequently definitive conclusions cannot be drawn. Overall, it seems that further adequate prospective, randomized studies are needed to define the better nutritional intervention in head and neck cancer patients undergoing chemoradiotherapy. This article is protected by copyright. All rights reserved.

Magnetic Resonance Guided Radiotherapy for Head and Neck Cancers

Radiotherapy is an integral component of head/neck squamous cell carcinomas (HNSCCs) treatment, and technological developments including advances in image-guided radiotherapy over the past decades have offered improvements in the technical treatment of these cancers. Integration of magnetic resonance imaging (MRI) into image guidance through the development of MR-guided radiotherapy (MRgRT) offers further potential for refinement of the techniques by which HNSCCs are treated. This article provides an overview of the literature supporting the current use of MRgRT for HNSCC, challenges with its use, and developing research areas.

Predictors of severe dysphagia following radiotherapy for head and neck cancer

OBJECTIVE

To investigate if severe dysphagia following radiotherapy for head and neck cancer (HNC) could be predicted by patient and tumor characteristics, feeding tube use, weight factors, jaw opening function, and saliva secretion.

METHODS

Data was collected from 94 HNC patients 6 to 36 months post radiotherapy. Swallowing function was assessed by videofluroscopy (VFS). Severe dysphagia was defined by Penetration Aspiration Scale (PAS) as PAS≥5 or a total score ≤60 on the M. D. Anderson Dysphagia Inventory (MDADI).

RESULTS

Thirty-three patients (35%) had PAS ≥5 and 19 (20%) a MDADI ≤60, that is, presented with severe dysphagia. Univariable logistic regression analysis (UVA) gave that tumor of the tonsil, overweight at time of VFS and each unit increase in Body Mass Index (BMI) predicted less risk of PAS ≥5. Dependency of feeding tube at time of VFS and each month's continued use and weight loss ≥7.5% since treatment to time of VFS predicted increased risk of PAS ≥5. Predictive variables from the UVA of PAS ≥5 (tumor of the tonsil, overweight, and total duration of feeding tube), were analyzed by multivariate logistic regression analysis. All retained power as independent predictors. UVA for MDADI showed that use of feeding tube at time of VFS predicted MDADI ≤60 with the risk increasing each month. Each increasing unit of BMI decreased risk of MDADI ≤60.

CONCLUSION

Long time users of feeding tube and higher weight-loss are at risk of severe dysphagia. This makes collaboration between professionals working with dysphagia an important step in detecting severe dysphagia.Level of Evidence: 3.

Swallowing Function Following Neoadjuvant Chemotherapy and Transoral Robotic Surgery for Oropharyngeal Carcinoma: A 2-Year Follow-up

OBJECTIVE

To evaluate 2-year follow-up swallowing function in patients with human papillomavirus-related oropharyngeal squamous cell carcinoma (HPV+ OPSCC) who completed neoadjuvant chemotherapy and transoral robotic surgery (NAC+S).

STUDY DESIGN

Retrospective analysis of patients with OPSCC treated with NAC+S between 2010 and 2021.

SETTING

A single academic institution.

METHODS

This is a cross-sectional study of patient-reported swallowing function, assessed with the MD Anderson Dysphagia Inventory (MDADI) at least 2 years after completion of treatment. The inclusion criteria are patients with HPV+ OPSCC who underwent NAC+S at least 2 years ago. Those requiring adjuvant radiation or chemoradiation or experiencing relapse were excluded from the study.

RESULTS

Completed MDADIs were received from 37 patients at a median 3.8 years posttreatment (interquartile range, 2.0-8.6 years). Of those, 94.6% (n = 35) were male and 81.1% (n = 30) were White. The median age at OPSCC diagnosis was 59.0 years (interquartile range, 41-80 years). The most frequent primary subsite of OPSCC was the base of the tongue (n = 20, 54.1%), followed by the tonsils (n = 16, 43.2%). In addition, 75.7% (n = 28) had stage IVa disease (TNM seventh edition), and 29 (78.4%) had scores ≥80, classified as optimal function. When compared with patients who received bilateral neck dissection, patients who received unilateral neck dissection were associated with an age <65 years old (P = .036) and lower clinical TNM stage (P = .04), as well as higher composite, emotional, functional, and physical MDADI scores (P = .017, .046, .013, and .05, respectively).

CONCLUSION

Patients with OPSCC who were treated with NAC+S achieved satisfactory long-term swallowing outcomes. Unilateral neck dissection was significantly associated with higher MDADI scores in this patient cohort.

Acupuncture for radiation-induced toxicity in head and neck squamous cell carcinoma: a systematic review based on PICO criteria

Purpose

In head and neck squamous cell carcinoma (HNSCC), the potential mitigating effect of complementary medicine interventions such as acupuncture for radiation-induced toxicity is unknown. This study aimed to assess the impact of acupuncture on the incidence and degree of severity of common radiation-induced side effects.

Methods

In accordance with pre-specified PICO criteria, a systematic review was performed. Two electronic databases (Medline and Embase) were searched over a 10-year time frame (01/01/10 to 30/09/20). Patients undergoing a curatively intended, radiation-based treatment for histologically confirmed squamous cell carcinoma of the nasopharynx, oropharynx, larynx, hypopharynx and oral cavity represented the target population of our study. Accurate information on the acupuncture methodology was reported. All included articles were evaluated to identify any potential source of bias

Results

Five papers were included in our qualitative analysis, for a total of 633 subjects. Compliance to per-protocol defined schedule of acupuncture sessions was high, ranging from 82 to 95.9%. Most patients (70.6%) were randomly allocated to receive acupuncture for its potential preventive effect on xerostomia. The large heterogeneity in study settings and clinical outcomes prevented from performing a cumulative quantitative analysis, thus no definitive recommendations can be provided.

Conclusions

Although shown to be feasible and safe, no firm evidence currently supports the use of acupuncture for the routine management of radiation-induced toxicity in HNSCC.

Gastrostomy tube dependence and patient-reported quality of life outcomes based on type of treatment for human papillomavirus-associated oropharyngeal cancer: Systematic review and meta-analysis

We examined the impact of treatment modality on gastrostomy tube dependence and patient-reported outcomes in human papillomavirus-associated oropharyngeal cancer (HPV-OPSCC). We performed systematic review and meta-analysis of functional outcomes 1-3 years after treatment. Twenty-three studies were included, reporting on 3127 patients treated for HPV-OPSCC. Gastrostomy tube dependence failed to show statistically significant difference between surgery with adjuvant therapy and chemoradiotherapy with cisplatin at 12 months (8.3% [95% CI: 3.1-15.9] vs. 4.2% [1.1-9.2], p = 0.37) and 24-36 months (10.5% [95% CI: 3.2-21.5] vs. 3.3% [2.0-4.9], p = 0.06). Surgery with adjuvant therapy was associated with worse University of Washington Quality of Life (UW-QOL) Swallowing (84 [95% CI: 80-88] vs. 89 [87-90], p = 0.03) and UW-QOL Overall scores (76 [95% CI: 72-80] vs. 84 [81-86], p = 0.001) compared to chemoradiotherapy with cisplatin at 12 months. Surgery with adjuvant therapy was associated with worse performance on certain measures of patient-reported swallow and overall function compared to chemoradiotherapy with cisplatin. Further randomized controlled trials are needed to directly compare functional outcomes after treatment for HPV-OPSCC.

Asymptomatic swallowing disorders may be present in individuals with laryngeal and hypopharyngeal cancer treated with chemo-radiotherapy

PURPOSE

Patients with advanced laryngeal and hypopharyngeal cancer are often treated with chemo-radiotherapy to avoid total laryngectomy. Subclinical swallowing disorders could be present in these patients even though patients do not complain of any symptoms. We sought to evaluate the impact of chemoradiation on swallowing and quality of life.

METHODS

We studied 21 patients undergoing chemo-radiotherapy for advanced laryngeal and hypopharyngeal cancer. All patients were tumor-free and none reported symptoms related to dysphagia during follow-up or showed altered routine screening tests (EAT-10) to detect it. Swallowing functions were assessed using volume-viscosity swallow test (V-VST) and fiberoptic endoscopic evaluation of swallowing (FEES). Quality of life was assessed with the EORT-H&N35, and SWAL-QOL scales.

RESULTS

Frequent alterations in swallowing efficacy (100%) and safety (85.5%) were detected with V-VST and FEES. Quality-of-life scales showed a reduction in their scores between 12 and 17%, mainly in the areas of symptoms.

CONCLUSION

Swallowing disorders are common after chemo-radiotherapy, even in patients who do not clinically manifest these disorders, contributing to a decrease in patients' quality of life. FEES and V-VST are useful procedures to detect asymptomatic swallowing disorders.

Intensity-modulated proton therapy for oropharyngeal cancer reduces rates of late xerostomia

BACKGROUND AND PURPOSE

To determine rates of xerostomia after intensity-modulated radiotherapy (IMRT) or intensity-modulated proton therapy (IMPT) for oropharyngeal cancer (OPC) and identify dosimetric factors associated with xerostomia risk.

MATERIALS AND METHODS

Patients with OPC who received IMRT (n = 429) or IMPT (n = 103) from January 2011 through June 2015 at a single institution were studied retrospectively. Every 3 months after treatment, each patient completed an eight-item self-reported xerostomia-specific questionnaire (XQ; summary XQ score, 0-100). An XQ score of 50 was selected as the demarcation value for moderate-severe (XQs ≥ 50) and no-mild (XQs < 50) xerostomia. The mean doses and percent volumes of organs at risk receiving various doses (V5-V70) were extracted from the initial treatment plans. The dosimetric variables and xerostomia risk were compared using an independent-sample t-test or chi-square test.

RESULTS

The median follow-up time was 36.2 months. The proportions of patients with moderate-severe xerostomia were similar in the two treatment groups up to 18 months after treatment. However, moderate-severe xerostomia was less common in the IMPT group than in the IMRT group at 18-24 months (6% vs. 20%; p = 0.025) and 24-36 months (6% vs. 20%; p = 0.01). During the late xerostomia period (24-36 months), high dose/volume exposures (V25-V70) in the oral cavity were associated with high proportions of patients with moderate-severe xerostomia (all p < 0.05), but dosimetric variables regarding the salivary glands were not associated with late xerostomia.

CONCLUSION

IMPT was associated with less late xerostomia than was IMRT in OPC patients. Oral cavity dosimetric variables were related to the occurrence of late xerostomia.

Randomized Clinical Trial on Reduction of Radiotherapy Dose to the Elective Neck in Head and Neck Squamous Cell Carcinoma: Results on the Quality of Life

PURPOSE

A randomized trial was initiated to investigate whether a reduction of the dose to the elective nodal sites would result in less toxicity and improvement in Quality of Life (QoL) without compromising tumor control. This paper aimed to compare QoL in both treatment arms.

METHODS

Two-hundred head and neck cancer patients treated with radiotherapy (RT) or chemo-RT were randomized (all stages, mean age: 60 years, M/F: 82%/18%). The elective nodal volumes of patients randomized in the experimental arm were treated up to a 40 Gy equivalent dose. In the standard arm, the elective nodal volumes were treated up to a 50 Gy equivalent dose. The QoL data were collected using The European Organization for Research and Treatment of Cancer (EORTC) core questionnaire QLQ-C30 and the EORTC Head and Neck Cancer module (H&N35).

RESULTS

A trend toward less decline in QoL during treatment was observed in the 40 Gy arm compared to the 50 Gy arm. Statistically significant differences for global health status, physical functioning, emotional functioning, speech problems, and trouble with social eating in favor of the 40 Gy arm were observed. A clinically relevant better outcome in the 40 Gy arm was found for physical functioning at the end of therapy.

CONCLUSION

QoL during RT for head and neck cancer tends to be less impaired in the 40 Gy arm. However, reducing the dose only on the elective neck does not result in clinically relevant improvement of QoL. Therefore, additional treatment strategies must be examined to further improve the QoL of HNSCC patients.

Biomechanical modeling of radiation dose-induced volumetric changes of the parotid glands for deformable image registration

PURPOSE

Early animal studies suggest that parotid gland (PG) toxicity prediction could be improved by an accurate estimation of the radiation dose to sub-regions of the PG. Translation to clinical investigation requires voxel-level dose accumulation in this organ that responds volumetrically throughout treatment. To date, deformable image registration (DIR) has been evaluated for the PG using only surface alignment. We sought to develop and evaluate an advanced DIR technique capable of modeling these complex PG volume changes over the course of radiation therapy.

MATERIALS AND METHODS

Planning and mid-treatment magnetic resonance images from 19 patients and computed tomography images from nine patients who underwent radiation therapy for head and neck cancer were retrospectively evaluated. A finite element model (FEM)-based DIR algorithm was applied between the corresponding pairs of images, based on boundary conditions on the PG surfaces only (Morfeus-spatial). To investigate an anticipated improvement in accuracy, we added a population model-based thermal expansion coefficient to simulate the dose distribution effect on the volume change inside the glands (Morfeus-spatialDose). The model accuracy was quantified using target registration error for magnetic resonance images, where corresponding anatomical landmarks could be identified. The potential clinical impact was evaluated using differences in mean dose, median dose, D98, and D50 of the PGs.

RESULTS

In the magnetic resonance images, the mean (±standard deviation) target registration error significantly reduced by 0.25 ± 0.38 mm (p = 0.01) when using Morfeus-spatialDose instead of Morfeus-spatial. In the computed tomography images, differences in the mean dose, median dose, D98, and D50 of the PGs reached 2.9 ± 0.8, 3.8, 4.1, and 3.8 Gy, respectively, between Morfeus-spatial and Morfeus-spatialDose.

CONCLUSION

Differences between Morfeus-spatial and Morfeus-spatialDose may be impactful when considering high-dose gradients of radiation in the PGs. The proposed DIR model can allow more accurate PG alignment than the standard model and improve dose estimation and toxicity prediction modeling.

Characterization of very late dysphagia after chemoradiation for oropharyngeal squamous cell carcinoma

OBJECTIVES

Improved prognosis for p16+ oropharyngeal squamous cell carcinoma (OPSCC) has led to efforts to mitigate long-term complications of treatment, which remains poorly defined in late survivors. Here we characterize very late dysphagia in OPSCC.

MATERIALS AND METHODS

Long-term review of 93 p16+ OPSCC patients treated with chemoradiation was performed. We scored videofluoroscopic swallow studies (VFSS) according to the Dynamic Imaging Grade of Swallowing Toxicity (DIGEST) scale. Very late dysphagia was defined >2.5 years from end of treatment. Fine-Gray regression models were used to assess dysphagia with competing risk of death.

RESULTS

Median follow up was 10.5 years. 402 total VFSS were assessed (median 4 per patient, range 0-8). 15.1% of patients had a DIGEST score ≥2 very late after treatment. Very late DIGEST score ≥2 correlated with T-stage (HR 1.7, p = 0.049), second cancer (HR 6.5, p = 0.004), superior pharyngeal constrictor dose (HR 1.11, p = 0.050), total tongue dose (HR 1.07, p = 0.045), but not hypoglossal nerve dose (p > 0.2). Seven patients (7.5%) had late progressive dysphagia, defined as DIGEST score that increased by ≥2 beyond one year after treatment, and this correlated with higher ipsilateral hypoglossal nerve D1cc dose (75 vs 72 Gy, p = 0.037).

CONCLUSION

In p16+ OPSCC patients treated with definitive chemoradiation, at least 7.5% developed late progressive dysphagia, and 15.1% experienced moderate dysphagia >2.5 years from treatment. Our study suggests that dose to tongue musculature may be associated with very late dysphagia, and hypoglossal nerve dose may be associated with late progressive dysphagia. More intensive long-term dysphagia survivorship monitoring is suggested.

Salivary Gland Hypofunction and Xerostomia in Head and Neck Radiation Patients

BACKGROUND

The most manifest long-term consequences of radiation therapy in the head and neck cancer patient are salivary gland hypofunction and a sensation of oral dryness (xerostomia).

METHODS

This critical review addresses the consequences of radiation injury to salivary gland tissue, the clinical management of salivary gland hypofunction and xerostomia, and current and potential strategies to prevent or reduce radiation injury to salivary gland tissue or restore the function of radiation-injured salivary gland tissue.

RESULTS

Salivary gland hypofunction and xerostomia have severe implications for oral functioning, maintenance of oral and general health, and quality of life. Significant progress has been made to spare salivary gland function chiefly due to advances in radiation techniques. Other strategies have also been developed, e.g., radioprotectors, identification and preservation/expansion of salivary stem cells by stimulation with cholinergic muscarinic agonists, and application of new lubricating or stimulatory agents, surgical transfer of submandibular glands, and acupuncture.

CONCLUSION

Many advances to manage salivary gland hypofunction and xerostomia induced by radiation therapy still only offer partial protection since they are often of short duration, lack the protective effects of saliva, or potentially have significant adverse effects. Intensity-modulated radiation therapy (IMRT), and its next step, proton therapy, have the greatest potential as a management strategy for permanently preserving salivary gland function in head and neck cancer patients.Presently, gene transfer to supplement fluid formation and stem cell transfer to increase the regenerative potential in radiation-damaged salivary glands are promising approaches for regaining function and/or regeneration of radiation-damaged salivary gland tissue.

Individualized Prophylactic Neck Irradiation in Patients with cN0 Head and Neck Cancer Based on Sentinel Lymph Node(s) Identification: Definitive Results of a Prospective Phase 1-2 Study

PURPOSE

This prospective, nonrandomized, interventional phase 1-2 study investigated the individualization of elective node irradiation in clinically N0 head and neck squamous cell carcinoma by sentinel lymph node (SLN) mapping with single-photon emission computed tomography/computed tomography (SPECT/CT) and its impact on tumor control and radiation-related toxicity.

METHODS AND MATERIALS

Forty-four patients with clinically N0 head and neck squamous cell carcinoma treated with definitive (chemo-)radiation therapy were imaged with SPECT/CT after ^99mTc nanocolloid injection around the tumor. The neck levels containing up to the 4 hottest SLNs were selected for prophylactic irradiation. A comparative virtual planning was performed with the selection of neck levels based on the current international guidelines. Regional control was monitored as a function of the selected volume. Dosimetric data for the organs at risk were compared between the plans. Normal tissue complication probability (NTCP) rates were derived for xerostomia, dysphagia, and hypothyroidism to predict the clinical benefit and correlated to quality-of-life (QoL) assessments at 6 months.

RESULTS

Sixteen percent of patients presented unpredicted lymphatic drainage, and 48% drained unilaterally. The nodal clinical target volume based on lymphoscintigraphy was smaller than the nodal clinical target volume based on international guidelines by a factor of 2 (P < .0001). After a median follow-up of 46 months, only 1 patient experienced a regional relapse in a nonirradiated area. Significant median dose reductions to organs at risk were observed, particularly to contralateral salivary glands in patients with unilateral drainage (14.6-28.1 Gy) and to the thyroid gland in all patients (22.4-48.9 Gy). Median NTCP reductions were observed for xerostomia (0.3% to 13.7%), dysphagia (1.7% to 10.8%), and hypothyroidism (14.0% to 36.1%). QoL at 6 months was improved, particularly in patients irradiated unilaterally.

CONCLUSIONS

Neck SLN mapping with SPECT/CT individualizes and reduces the elective nodal target volumes without compromising the regional control. The NTCP rates were reduced and favorable QoL were observed in all patients, particularly in the case of unilateral irradiation.

Dose Reduction to the Swallowing Apparatus and the Salivary Glands by De-Intensification of Postoperative Radiotherapy in Patients with Head and Neck Cancer: First (Treatment Planning) Results of the Prospective Multicenter DIREKHT Trial

Aim: Evaluating radiotherapy treatment plans of the prospective DIREKHT trial (ClinicalTrials.gov, NCT02528955) investigating de-intensification of radiotherapy in patients with head and neck cancer. Patients and Methods: The first 30 patients from the DIREKHT trial of the leading study centre were included in this analysis. Standard treatment plans and study treatment plans derived from the protocol were calculated for each patient. Sizes of planning target volumes (PTVs) and mean doses to organs at risk were compared using the Student’s t-test with paired samples. Results: Mean PTV3 including primary tumor region and ipsilateral elective neck up to a dose of 50 Gy in the study treatment plans was 662 mL (+/− 165 mL standard deviation (SD)) and therefore significantly smaller than those of the standard treatment plans (1166 mL (+/− 266 mL SD). In the medial and inferior constrictor muscles, cricopharyngeal muscle, glottic and supraglottic laryngeal areas, arytenoid cartilages, contralateral major salivary glands highly significant dose reductions (p < 0.0001) of more than 10 Gy were achieved in study treatment plan compared to standard treatment plan. Conclusion: De-intensification of radiotherapy led to smaller planning target volumes and clinical relevant dose reductions in the swallowing apparatus and in the contralateral salivary glands.

Interactive website for head and neck cancer patients: Adherence and coping program to prevent dysphagia after radiation

INTRODUCTION

Pharyngeal and laryngeal cancers are highly curable; however survivors are at high risk for long-term dysphagia after radiation. To address lack of access to preventive care in community settings, we developed a responsive web-based application to help patients adhere to preventive swallowing exercises and cope with radiation side effects. We conducted an interim study analysis to determine website usage characteristics and to examine the effect size for future trials.

METHODS

Pharyngeal and laryngeal cancer patients were recruited for enrollment by speech language pathologists before primary radiation and introduced to the interactive website. The program (English and Spanish) features tracking logs for preventive exercises, instructional videos, patient stories and search features. Patients' self-reported swallowing function was assessed with the MD Anderson Dysphagia Inventory (MDADI) at baseline and at 6 months. Adherence to preventive exercises was assessed during the 10 week intervention. Number of unique website visits, total duration of website exposure, and rankings of the most popular webpages were calculated. Preliminary regression models were run using adherence and MDADI as outcomes.

RESULTS

Of the 160 enrolled, 96 had 10-week adherence data and 61 had 6-month MDADI data. The average age was 63 (SD = 12.26), 49.4% were from rural counties, 44% had a high school education or lower, and 42% reported annual income of $30,000 or less. The average number of visits was 5.49 (SD = 9.96) and the average total time spent with the website was 41.09 min (SD =88.48). Preliminary analyses indicated that number of unique visits to the website was independently associated with increased adherence to preventive exercises (p = .001-.008).

CONCLUSION

Our website showed significant effects in promoting adherence to swallowing exercises. However, our return visit rate showed that the platform needs improvement in navigability and usability for this older population undergoing challenging treatment in community settings with low resources.

Emotional Quality of Life After Radiation Therapy for Oropharyngeal Carcinoma

Purpose

Substantial research exists on the physical toxicities from radiation therapy (RT) for oropharyngeal cancers, but emotional quality of life is understudied. The purpose of this study is to map the effects and time course of radiation-related changes in mood and anxiety and to investigate the physical factors that drive these changes.

Methods and materials

We prospectively collected University of Washington Quality of Life questionnaires and identified patients with oropharyngeal cancer who were treated with curative-intent RT between 2013 and 2016 and had completed questionnaires within 12 months after RT (n = 69). We analyzed swallow, saliva, taste, chewing, speech, pain, mood, and anxiety scores, using a scale from 0 to 100. We conducted a multivariate regression analysis to identify physical functioning predictors of worse emotional scores.

Results

Physical functioning scores declined from before RT to 3 months after RT and then began improving but did not rebound to baseline levels within 12 months. Patient mood slightly declined, but anxiety improved immediately after RT, with both generally improving such that scores were higher at the 12-month follow-up than at initial consult. Analysis showed that longer duration of treatment is associated with a higher likelihood of worse mood scores at 12 months (odds ratio [OR], 1.446; P < .01). Worse swallow score is associated with a greater likelihood of worse mood score at 3 months (OR, 0.971; P < .01) and 12 months (OR, 0.975; P < .01). A worse taste score is associated with a greater likelihood of worse anxiety score at 3 months (OR, 0.979; P < .05) and 12 months (OR, 0.982; P < .05).

Conclusions

Emotional changes are associated with certain treatment-associated toxicities. A patient's emotional health is complex and likely multifactorial in nature. Our study identified key associations and time points to potentially intervene upon.

Organ Preservation and Late Functional Outcome in Oropharyngeal Carcinoma: Rationale of EORTC 1420, the "Best of" Trial

Dysphagia represents one of the most serious adverse events after curative-intent treatments with a tremendous impact on quality of life in patients with head and neck cancers. Novel surgical and radiation therapy techniques have been developed to better preserve swallowing function, while not negatively influencing local control and/or overall survival. This review focuses on the current literature of swallowing outcomes after curative treatment strategies. Available results from recent studies relevant to this topic are presented, demonstrating the potential role of new treatment modalities for early- and intermediate-stage oropharyngeal cancers. Based on this, we present the rationale and design of the currently active EORTC 1420 "Best of" trial, and highlight the potential of this study to help prioritizing either surgery- or radiation-based treatment modalities for the treatment of oropharyngeal cancer in the future.

Biomechanical modeling of neck flexion for deformable alignment of the salivary glands in head and neck cancer images

During head and neck (HN) cancer radiation therapy, analysis of the dose-response relationship for the parotid glands (PG) relies on the ability to accurately align soft tissue organs between longitudinal images. In order to isolate the response of the salivary glands to delivered dose, from deformation due to patient position, it is important to resolve the patient postural changes, mainly due to neck flexion. In this study we evaluate the use of a biomechanical model-based deformable image registration (DIR) algorithm to estimate the displacements and deformations of the salivary glands due to postural changes. A total of 82 pairs of CT images of HN cancer patients with varying angles of neck flexion were retrospectively obtained. The pairs of CTs of each patient were aligned using bone-based rigid registration. The images were then deformed using biomechanical model-based DIR method that focused on the mandible, C1 vertebrae, C3 vertebrae, and external contour. For comparison, an intensity-based DIR was also performed. The accuracy of the biomechanical model-based DIR was assessed using Dice similarity coefficient (DSC) for all images and for the subset of images where the PGs had a volume change within 20%. The accuracy was compared to the intensity-based DIR. The PG mean  ±  STD DSC were 0.63  ±  0.18, 0.80  ±  0.08, and 0.82  ±  0.15 for the rigid registration, biomechanical model-based DIR, and intensity based DIR, respectively, for patients with a PG volume change up to 20%. For the entire cohort of patients, where the PG volume change was up to 57%, the PG mean  ±  STD DSC were 0.60  ±  0.18, 0.78  ±  0.09, and 0.81  ±  0.14 for the rigid registration, biomechanical model-based DIR, and intensity based DIR, respectively. The difference in DSC of the intensity and biomechanical model-based DIR methods was not statistically significant when the volume change was less than 20% (two-sided paired t-test, p   =  0.12). When all volume changes were considered, there was a significant difference between the two registration approaches, although the magnitude was small. These results demonstrate that the proposed biomechanical model with boundary conditions on the bony anatomy can serve to describe the varying angles of neck flexion appearing in images during radiation treatment and to align the salivary glands for proper analysis of dose-response relationships. It also motivates the need for dose response modeling following neck flexion for cases where parotid gland response is noted.

Xerostomia-related quality of life for patients with oropharyngeal carcinoma treated with proton therapy

PURPOSE

We report longitudinal patient-reported quality-of-life (QoL) outcomes related to xerostomia in patients with oropharyngeal cancer treated with intensity-modulated proton therapy (IMPT).

MATERIALS AND METHODS

Patients treated from May 2012 through December 2016 at a single institution for AJCC7 stage III-IV, M0 oropharyngeal cancer were given the 15-item Xerostomia-Related QoL Scale (XeQoLS) before, during, and for up to 2 years after treatment. We evaluated the evolution of xerostomia-related QoL over that time, and examined potential associations between those measures with clinical characteristics.

RESULTS

Sixty-nine patients had XeQoLS scores at baseline and at least once either during or after treatment. The mean (±SD) XeQoLS score (0-4) was 0.24 ± 0.57 at baseline. Subsequent scores were 2.00 ± 1.01 at 6 weeks on treatment, and 1.03 ± 0.76, 0.97 ± 0.78, 0.82 ± 0.69, and 0.70 ± 0.75 at 10 weeks, 6 months, 1 year, and 2 years after treatment, respectively. All were statistically different from baseline (p < 0.001). Univariate analyses demonstrated associations between XeQoLS score and time (p < 0.0001 for each interval), baseline XeQoLS score (p < 0.0001), stage (p = 0.008), N status (p = 0.006), and mean oral cavity dose (p = 0.038), but not for age, sex, T status, receipt of chemotherapy, smoking history, disease site, laterality of neck irradiation, mean parotid dose, or mean submandibular dose. Multivariate analysis suggested that baseline XeQoLS scores, phase of treatment, and N status were associated with XeQoLS scores measured during treatment and recovery.

CONCLUSIONS

Patients receiving IMPT reported the greatest xerostomia-related QoL impairment at 6 weeks on treatment, with a 49% improvement by 10 weeks after treatment; however, XeQoLS scores remained above baseline after 2 years. As we aim to establish the value of IMPT in oropharyngeal tumors to de-intensify treatment over conventional therapy, these data help inform discussions about xerostomia-related quality of life for patients with oropharyngeal cancer treated with IMPT.

Long-Term Aspects of Quality of Life in Head and Neck Cancer Patients Treated With Intensity Modulated Radiation Therapy: A 5-Year Longitudinal Follow-up and Comparison with a Normal Population Cohort

Purpose

Knowledge of long-term health-related quality of life (HRQOL) in patients with advanced head and neck cancer treated with intensity modulated radiation therapy is scarce.

Methods and Materials

HRQOL in 126 patients with advanced head and neck cancer treated with intensity modulated radiation therapy was followed longitudinally from diagnosis to 5 years after treatment with the European Organization for Research and Treatment of Cancer's QLQ-C30, the European Organization for Research and Treatment of Cancer's Head and Neck Cancer Module, and the M.D. Anderson Dysphagia Inventory. The survivors' HRQOL was compared with an age- and sex-matched normal population cohort.

Results

At 5 years, 73 of the 95 surviving patients had completed the study. Significant reductions in general pain (29 vs 12), head and neck (HN) pain (22 vs 14), and feeling ill (20 vs 10) were found, and emotional functioning (70 vs 83) and global quality of life (67 vs 74) improved, compared with baseline values. Conversely, dry mouth (19 vs 56), senses (8 vs 27), teeth problems (10 vs 22), opening mouth (19 vs 56), and sticky saliva (15 vs 40) were markedly worse, although significant improvements had occurred over time after treatment. Anderson Dysphagia Inventory scores >80 at 5 years indicated good swallowing function. In a subgroup analysis, dry mouth and senses were significantly better in patients treated with chemoradiotherapy. Comparison to a normal population cohort's HRQOL shows that the study group experienced a wide array of symptoms affecting their quality of life.

Conclusions

The results of this large, long-term follow-up study show that a majority of patients report a reasonable quality of life 5 years after treatment and that there seems to be continuous improvement over time. Comparison with a normal population cohort, however, underlines the fact that classical side effects remain, even with improved radiation techniques. Additional emphasis on normal-tissue-sparing radiation therapy is warranted, with close attention devoted to HRQOL outcomes.

The impact of time after radiation treatment on dysphagia in patients with head and neck cancer enrolled in a swallowing therapy program

BACKGROUND

Swallowing dysfunction after radiotherapy (RT) for head and neck cancer can be devastating. A randomized control trial compared swallow exercises versus exercise plus neuromuscular electrical stimulation therapy and found no overall difference in outcomes.

METHODS

Quality of life (QOL), diet, and swallowing variables collected at discrete intervals on 117 patients were reanalyzed to test the hypothesis that shorter time between the completion of radiotherapy and beginning of the swallowing therapy program yielded improved outcomes.

RESULTS

At baseline, subjects < 1 year post radiation had significantly better function than subjects >2 years post RT in several measures. Over the therapy program, the early group showed significant improvement in diet and QOL. Swallowing physiologic variables showed no difference between groups.

CONCLUSION

Beginning a swallowing therapy program within 1 year of completion of radiotherapy demonstrates more consistent improvement in QOL and diet performance compared to later periods.

Treatment preferences in human papillomavirus-associated oropharyngeal cancer

The population of survivors with human papillomavirus-associated oropharyngeal squamous cell carcinoma (HPV-OPSCC) is rising. The improved prognosis of this etiologic subset is reflected in new staging guidelines as well as ongoing deintensification trials aiming to preserve excellent survival while decreasing treatment-related toxicities. However, as staging criteria and treatment standards evolve in the era of transoral surgery and deintensification, little is known regarding the needs and treatment preferences of patients with HPV-OPSCC. Herein, the current knowledge regarding treatment preferences and priorities, quality of life and concerns among patients with HPV-OPSCC is reviewed.

Long-term survival and swallowing outcomes in advanced stage oropharyngeal squamous cell carcinomas

BACKGROUND

There is a paucity of studies reporting long-term survival outcomes for HPV/p16 positive oropharyngeal squamous cell carcinoma (OPSCC). This study aims to compare long-term outcomes of advanced stage p16 positive and negative OPSCCs, treated by surgical and non-surgical modalities.

METHODS

OPSCC patients from 1998 to 2012 were identified through a prospectively collected cancer registry. P16 immunohistochemistry was used as a surrogate marker for HPV-OPSCC. Overall survival (OS) and aspiration free survival (AFS) comparisons were made between patients treated with chemoradiation (CRT) versus primary surgery and radiation/chemoradiation (S+RT/CRT) at 5, 10 and 15 years post-treatment.

RESULTS

A total of 319 patients were included. P16 positive patients and non-smokers had significantly higher long-term (5, 10 and 15-year) OS. Smokers and p16 negative patients treated with S+RT/CRT had improved long-term OS compared to patients who received CRT. Smokers and p16 negative patients had lower long-term AFS. Multivariate analysis showed improved OS was associated with p16 positivity (HR 0.42, 0.28-0.61) and surgery (HR 0.47, 0.32-0.69), whereas lower OS was associated with ECOG ≥ 2 (HR 2.46, 1.61-3.77), smoking (HR 2.37, 1.41-3.99) and higher stage (HR 1.68, 1.05-2.68).

CONCLUSIONS

In smokers and p16-negative OPSCC patients, primary surgery may be associated with improved long-term survival and dysphagia-related outcomes.

Gold nanoparticles enhance X-ray irradiation-induced apoptosis in head and neck squamous cell carcinoma in vitro

Enhancing the antitumor effect of radiation, while reducing damage to organs, is a significant challenge in radiation therapy for head and neck malignancies. One promising radiosensitizer is gold. The present study aimed to determine whether gold nanoparticles (AuNPs) have the potential to enhance the effects of X-ray irradiation on head and neck cancer cells. The human head and neck carcinoma cell line HSC-3 was used. Total cell number and the levels of cell proliferation and apoptosis were compared between control cells and cells treated with 5-nm AuNPs alone at four concentrations (0.1, 0.4, 1.0 and 10.0 nM), X-ray irradiation alone at three doses (2, 4 and 8 Gy), or a combination of 4 Gy X-ray irradiation and 1.0 nM AuNPs. Analysis of variance and Tukey-Kramer testing were performed to compare the different groups. The total number of cells significantly decreased following 4 and 8 Gy X-ray irradiation, compared with in the control group (control vs. 4Gy, P=2.19×10^-4; control vs. 8Gy, P=1.28×10^-6). The combination of 4 Gy X-ray irradiation and 1.0 nM AuNPs significantly reduced the total number of cells compared with 4 Gy X-ray irradiation alone (P=2.95×10^-4). Cell proliferation was not affected by AuNP treatment alone, 4 Gy X-ray irradiation alone or the combination of X-ray irradiation and AuNPs. The combination of 4 Gy irradiation and 1.0 nM AuNPs significantly increased the number of apoptotic cells compared with 4 Gy irradiation alone (P=0.0261). In conclusion, AuNPs combined with X-ray irradiation enhanced the cytotoxic effect on human head and neck cancer cells in vitro, through the induction of apoptosis, but not inhibition of cell proliferation.

Quality of life in oropharyngeal cancer: a structured review of the literature

PURPOSE

To summarize the literature on quality of life (QoL) in patients with oropharyngeal squamous cell carcinoma (OPSCC).

METHODS

The PubMed database was searched using the inclusion criteria "oropharyngeal cancer," "quality of life," "human," and "English," the exclusion criterion "recurrent," and publication date between January 1, 2005 and October 26, 2015.

RESULTS

The search yielded 98 articles of which 17 fulfilled all selection criteria. Intensity-modulated radiotherapy (IMRT) showed a better outcome for several QoL domains and was superior to chemoradiotherapy (CRT) in some studies. At 12-month follow up, deterioration of QoL was seen in a smaller proportion of patients after surgery and postoperative radiotherapy (S&PORT) in comparison to CRT. For all treatment modalities, the most important worsening for several QoL domains was seen at 3 months. Stage III/IV patients experienced a greater deterioration of QoL scores for most scores. No consistent results were reported for the correlation between xerostomia assessed with QoL questionnaires and objective swallowing function assessed with modified barium swallow videofluoroscopy.

CONCLUSION

The different tools used for the assessment of patient-reported QoL and objective measurement of functional outcome make it difficult to evaluate the effect of different treatment modalities. In general, we can conclude that a non-surgical approach is associated with worse QoL scores. IMRT minimizes radiation to the surrounding tissue and therefore has a better outcome in several QoL domains in comparison to conventional RT.

Functional Outcomes After De-escalated Chemoradiation Therapy for Human Papillomavirus-Positive Oropharyngeal Cancer: Secondary Analysis of a Phase 2 Trial

PURPOSE

To analyze functional outcomes for patients treated on a phase 2 trial of de-escalated chemoradiation therapy for human papillomavirus-positive oropharyngeal cancer.

METHODS AND MATERIALS

Patient eligibility included p16-positive, stage III or IV oropharyngeal squamous cell carcinoma and a Zubrod performance status of 0 to 1. Treatment was induction chemotherapy with paclitaxel, 175 mg/m², and carboplatin, area under the curve (AUC) of 6 mg/ml/min, for 2 cycles every 21 days, followed by concurrent paclitaxel, 30 mg/m², every 7 days with dose-reduced radiation therapy of 54 or 60 Gy. Trends in body weight and body mass index (BMI) were analyzed with gastrostomy tube and narcotic use rates. Functional outcomes were assessed using the University of Washington Quality of Life Scale and the Functional Assessment of Cancer Therapy-Head and Neck Scale.

RESULTS

Forty-five patients were registered, of whom 40 were evaluable. Only 1 patient had a BMI deemed unhealthy at the completion of treatment. For the 15 patients (38%) with a normal BMI (18-25 kg/m²) before treatment, recovery back to baseline occurred at approximately 18 months (average BMI, 23.2 kg/m² vs 22.3 kg/m²; P=.09). In 2 patients (5%), gastrostomy tubes were placed during treatment. No patient was enteral feeding tube-dependent at 6 months after treatment. Ninety-five percent of patients tolerated a normal regular diet at last follow-up.

CONCLUSIONS

De-escalated chemoradiation therapy may improve functional outcomes as indicated by the relatively low incidence of gastrostomy tube placement and long-term dysphagia. In patients with a normal BMI prior to chemoradiation therapy, BMI recovered to baseline levels.

Patient-reported quality-of-life outcomes after de-escalated chemoradiation for human papillomavirus-positive oropharyngeal carcinoma: Findings from a phase 2 trial

BACKGROUND

The current study represents a subset analysis of quality-of-life (QOL) outcomes among patients treated on a phase 2 trial of de-escalated chemoradiation for human papillomavirus (HPV)-associated oropharyngeal cancer.

METHODS

Eligibility included newly diagnosed, (American Joint Committee on Cancer, 7th edition) stage III or IV oropharyngeal squamous cell carcinoma, p16 positivity, age ≥ 18 years, and a Zubrod performance status of 0 to 1. Treatment was induction paclitaxel at a dose of 175 mg/m² and carboplatin at an area under the curve of 6 for 2 cycles followed by response-adapted, dose-reduced radiation of 54 Gy or 60 Gy with weekly concurrent paclitaxel at a dose of 30 mg/m² . The University of Washington Quality of Life (UW-QOL) and the Functional Assessment of Cancer Therapy-Head and Neck questionnaires were used to assess patient-reported QOL as a secondary endpoint.

RESULTS

A total of 45 patients were registered, 40 of whom completed QOL surveys and were evaluable. Nadirs for overall UW-QOL and Functional Assessment of Cancer Therapy-Head and Neck scores were reached at 4 weeks after treatment but returned to baseline at 3 months. Nearly all functional indices returned to baseline levels by 6 to 9 months. The mean overall UW-QOL score was 71.6 at baseline compared with 70.8, 73.0, 83.3, and 81.1, respectively, at 3 months, 6 months, 1 year, and 2 years after therapy. The percentage of patients rating their overall QOL as "very good" or "outstanding" at 6 months, 1 year, and 2 years using the UW-QOL was 50%, 77%, and 84%, respectively.

CONCLUSIONS

This de-escalation regimen achieved QOL outcomes that were favorable compared with historical controls. These results serve as powerful evidence that ongoing de-escalation efforts lead to tangible gains in function and QOL. Cancer 2018;124:521-9. © 2017 American Cancer Society.

Systematic Review of Normal Tissue Complication Models Relevant to Standard Fractionation Radiation Therapy of the Head and Neck Region Published After the QUANTEC Reports

There has recently been an increasing interest in model-based evaluation and comparison of different treatment options in radiation oncology studies. This is partly driven by the considerable technical advancements in radiation therapy of the last decade, leaving radiation oncologists with a multitude of options to consider. In lieu of randomized trials comparing all of these different treatment options for varying indications, which is unfeasible, treatment evaluations based on normal tissue complication probability (NTCP) models offer a practical alternative. The Quantitative Analyses of Normal Tissue Effects in the Clinic (QUANTEC) effort, culminating in a number of reports published in 2010, provided a basis for many of the since-implemented dose-response models and dose-volume constraints and was a key component for model-based treatment evaluations. Given that 7 years have passed since the QUANTEC publications and that patient-reported outcomes have emerged as an important consideration in recent years, an updated summary of the published radiation dose-response literature, which includes a focus on patient-reported quality of life outcomes, is warranted. Here we provide a systematic review of quantitative dose-response models published after January 1, 2010 for endpoints relevant to radiation therapy for head and neck cancer, because these patients are typically at risk for a variety of treatment-induced normal tissue complications.

Long-term patient reported outcomes following radiation therapy for oropharyngeal cancer: cross-sectional assessment of a prospective symptom survey in patients ≥65 years old

Background

Given the potential for older patients to experience exaggerated toxicity and symptoms, this study was performed to characterize patient reported outcomes in older patients following definitive radiation therapy (RT) for oropharyngeal cancer (OPC).

Methods

Cancer-free head and neck cancer survivors (>6 months since treatment completion) were eligible for participation in a questionnaire-based study. Participants completed the MD Anderson Symptom Inventory-Head and Neck module (MDASI-HN). Those patients ≥65 years old at treatment for OPC with definitive RT were included. Individual and overall symptom severity and clinical variables were analyzed.

Results

Of the 79 participants analyzed, 82% were male, 95% white, 41% T3/4 disease, 39% RT alone, 27% induction chemotherapy, 52% concurrent, and 18% both, and 96% IMRT. Median age at RT was 71 yrs. (range: 65–85); median time from RT to MDASI-HN was 46 mos. (2/3 > 24 mos.). The top 5 MDASI-HN items rated most severe in terms of mean (±SD) ratings (0–10 scale) were dry mouth (3.48 ± 2.95), taste (2.81 ± 3.29), swallowing (2.59 ± 2.96), mucus in mouth/throat (2.04 ± 2.68), and choking (1.30 ± 2.38) reported at moderate-severe levels (≥5) by 35, 29, 29, 18, and 13%, respectively. Thirty-nine % reported none (0) or no more than mild (1–4) symptoms across all 22 MDASI-HN symptoms items, and 38% had at least one item rated as severe (≥7). Hierarchical cluster analysis resulted in 3 patient groups: 1) ~65% with ranging from none to moderate symptom burden, 2) ~35% with moderate-severe ratings for a subset of classically RT-related symptoms (e.g. dry mouth, mucus, swallowing) and 3) 2 pts. with severe ratings of most items.

Conclusions

The overall long-term symptom burden seen in this older OPC cohort treated with modern standard therapy was largely favorable, yet a higher symptom group (~35%) with a distinct pattern of mostly local and classically RT-related symptoms was identified.

Electronic supplementary material

The online version of this article doi: (10.1186/s13014-017-0878-9) contains supplementary material, which is available to authorized users.

Assessment of PlanIQ Feasibility DVH for head and neck treatment planning

Introduction

Designing a radiation plan that optimally delivers both target coverage and normal tissue sparing is challenging. There are limited tools to determine what is dosimetrically achievable and frequently the experience of the planner/physician is relied upon to make these determinations. PlanIQ software provides a tool that uses target and organ at risk (OAR) geometry to indicate the difficulty of achieving different points for organ dose–volume histograms (DVH). We hypothesized that PlanIQ Feasibility DVH may aid planners in reducing dose to OARs.

Methods and materials

Clinically delivered head and neck treatments (clinical plan) were re‐planned (re‐plan) putting high emphasis on maximally sparing the contralateral parotid gland, contralateral submandibular gland, and larynx while maintaining routine clinical dosimetric objectives. The planner was blinded to the results of the clinically delivered plan as well as the Feasibility DVHs from PlanIQ. The re‐plan treatments were designed using 3‐arc VMAT in Raystation (RaySearch Laboratories, Sweden). The planner was then given the results from the PlanIQ Feasibility DVH analysis and developed an additional plan incorporating this information using 4‐arc VMAT (IQ plan). The DVHs across the three treatment plans were compared with what was deemed “impossible” by PlanIQ's Feasibility DVH (Impossible DVH). The impossible DVH (red) is defined as the DVH generated using the minimal dose that any voxel outside the targets must receive given 100% target coverage.

Results

The re‐plans performed blinded to PlanIQ Feasibilty DVH achieved superior sparing of aforementioned OARs compared to the clinically delivered plans and resulted in discrepancies from the impossible DVHs by an average of 200–700 cGy. Using the PlanIQ Feasibility DVH led to additionalOAR sparing compared to both the re‐plans and clinical plans and reduced the discrepancies from the impossible DVHs to an average of approximately 100 cGy. The dose reduction from clinical to re‐plan and re‐plan to IQ plan were significantly different even when taking into account multiple hypothesis testing for both the contralateral parotid and the larynx (P < 0.004 for all comparisons). No significant differences were observed between the three plans for the contralateral parotid when considering multiple hypothesis testing.

Conclusions

Clinical treatment plans and blinded re‐plans were found to suboptimally spare OARs. PlanIQ could aid planners in generating treatment plans that push the limits of OAR sparing while maintaining routine clinical target coverage goals.

Grading Dysphagia as a Toxicity of Head and Neck Cancer: Differences in Severity Classification Based on MBS DIGEST and Clinical CTCAE Grades

Clinician-reported toxicity grading through common terminology criteria for adverse events (CTCAE) stages dysphagia based on symptoms, diet, and tube dependence. The new dynamic imaging grade of swallowing toxicity (DIGEST) tool offers a similarly scaled five-point ordinal summary grade of pharyngeal swallowing as determined through results of a modified barium swallow (MBS) study. This study aims to inform clinicians on the similarities and differences between dysphagia severity according to clinical CTCAE and MBS-derived DIGEST grading. A cross-sectional sample of 95 MBS studies was randomly selected from a prospectively-acquired MBS database among patients treated with organ preservation strategies for head and neck cancer. MBS DIGEST and clinical CTCAE dysphagia grades were compared. DIGEST and CTCAE dysphagia grades had "fair" agreement per weighted κ of 0.358 (95% CI .231-.485). Using a threshold of DIGEST ≥ 3 as reference, CTCAE had an overall sensitivity of 0.50, specificity of 0.84, and area under the curve (AUC) of 0.67 to identify severe MBS-detected dysphagia. At less than 6 months, sensitivity was 0.72, specificity was 0.76, and AUC was 0.75 while at greater than 6 months, sensitivity was 0.22, specificity was 0.90, and AUC was 0.56 for CTCAE to detect dysphagia as determined by DIGEST. Classification of pharyngeal dysphagia on MBS using DIGEST augments our understanding of dysphagia severity according to the clinically-derived CTCAE while maintaining the simplicity of an ordinal scale. DIGEST likely complements CTCAE toxicity grading through improved specificity for physiologic dysphagia in the acute phase and improved sensitivity for dysphagia in the late-phase.